Epidemiologic and genomic insights on mcr-1-harbouring Salmonella from diarrhoeal outpatients in Shanghai, China, 2006-2016

BACKGROUND

Colistin resistance mediated by mcr-1-harbouring plasmids is an emerging threat in Enterobacteriaceae, like Salmonella. Based on its major contribution to the diarrhoea burden, the epidemic state and threat of mcr-1-harbouring Salmonella in community-acquired infections should be estimated.

METHODS

This retrospective study analysed the mcr-1 gene incidence in Salmonella strains collected from a surveillance on diarrhoeal outpatients in Shanghai Municipality, China, 2006-2016. Molecular characteristics of the mcr-1-positive strains and their plasmids were determined by genome sequencing. The transfer abilities of these plasmids were measured with various conjugation strains, species, and serotypes.

FINDINGS

Among the 12,053 Salmonella isolates, 37 mcr-1-harbouring strains, in which 35 were serovar Typhimurium, were detected first in 2012 and with increasing frequency after 2015. Most patients infected with mcr-1-harbouring strains were aged <5 years. All strains, including fluoroquinolone-resistant and/or extended-spectrum β-lactamase-producing strains, were multi-drug resistant. S. Typhimurium had higher mcr-1 plasmid acquisition ability compared with other common serovars. Phylogeny based on the genomes combined with complete plasmid sequences revealed some clusters, suggesting the presence of mcr-1-harbouring Salmonella outbreaks in the community. Most mcr-1-positive strains were clustered together with the pork strains, strongly suggesting pork consumption as a main infection source.

INTERPRETATION

The mcr-1-harbouring Salmonella prevalence in community-acquired diarrhoea displays a rapid increase trend, and the ESBL-mcr-1-harbouring Salmonella poses a threat for children. These findings highlight the necessary and significance of prohibiting colistin use in animals and continuous monitoring of mcr-1-harbouring Salmonella.

Incidence of Norovirus-Associated Diarrhea, Shanghai, China, 2012-2013

We conducted sentinel-based surveillance for norovirus in the Pudong area of Shanghai, China, during 2012–2013, by analyzing 5,324 community surveys, 408,024 medical records, and 771 laboratory-confirmed norovirus infections among 3,877 diarrhea cases. Our analysis indicated an outpatient incidence of 1.5/100 person-years and a community incidence of 8.9/100 person-years for norovirus-associated diarrhea.

Multidrug-Resistant Shigella Infections in Patients with Diarrhea, Cambodia, 2014-2015

We observed multidrug resistance in 10 (91%) of 11 Shigella isolates from a diarrheal surveillance study in Cambodia. One isolate was resistant to fluoroquinolones and cephalosporins and showed decreased susceptibility to azithromycin. We found mutations in gyrA, parC, β-lactamase, and mphA genes. Multidrug resistance increases concern about shigellosis treatment options.

George Murray Levick (1876-1956), Antarctic explorer

Murray Levick is best known for being one of the surgeons on Scott's Terra Nova Antarctic expedition (1910-1913) and, as a member of the Northern Party of that expedition, spending a winter living in a snow hole when the ship was unable to collect the men. However, his career encompassed much more than that. He served in the Royal Navy during both World Wars and was a pioneer in physical medicine and rehabilitation. He also founded the British Schools Exploring Society.

Overview and Historical Perspectives

In this overview, we describe the history of Shiga toxin (Stx)-producing Escherichia coli (STEC) in two phases. In phase one, between 1977 and 2011, we learned that E. coli could produce Shiga toxin and cause both hemorrhagic colitis and the hemolytic-uremic syndrome in humans and that the prototype STEC-E. coli O157:H7-adheres to and effaces intestinal epithelial cells by a mechanism similar to that of enteropathogenic E. coli. We also recognized that the genes for Stx are typically encoded on a lysogenic phage; that STEC O157:H7 harbors a large pathogenicity island that encodes the elements needed for the characteristic attaching and effacing lesion; and that the most severe cases of human disease are linked to production of Stx type 2a, not Stx type 1a. Phase two began with a large food-borne outbreak of hemorrhagic colitis and hemolytic-uremic syndrome in Germany in 2011. That outbreak was caused by a novel strain consisting of enteroaggregative E. coli O104:H4 transduced by a Stx2a-converting phage. From this outbreak we learned that any E. coli strain that can adhere tightly to the human bowel (either by a biofilm-like mechanism as in E. coli O104:H4 or by an attaching and effacing mechanism as in E. coli O157:H7) can cause severe diarrheal and systemic illness when it acquires the capacity to produce Stx2a. This overview provides the basis for the review of current information regarding these fascinating and complex pathogens.

[Analysis on characteristics of meridians and acupoints of acupuncture and moxibustion for diarrhea in ancient based on data mining]

The data in literature of acupuncture and moxibustion on treatment of diarrhea from pre-Qin period to Qing dynasty was collected to establish prescription database and characteristics and rules of ancient acupuncture and moxibustion for diarrhea were analyzed with data mining technology. Totally 235 papers were collected and 76 acupoints were involved with 439 times of selection. The number and times of special acupoints were 72.37% (55/76) and 76.99% (338/439), respectively, which was more seen in front-mu acupoint and back-shu acupoint. The acupoints were distributed among 11 meridians. Moxibustion was applied in 53 papers while combination of acupuncture and moxibustion was used in 1 literature. As a result, acupuncture and moxibustion for diarrhea in ancient pay much attention on acupoint in back and abdomen, in which Tianshu (ST 25), Shen-que (CV 8), Guanyuan (CV 4) and Dachangshu (BL 25) were the most frequently used. The compatibility of front-mu acupoint and back-shu acupoint was very common. Selection of special acupoint was dominant. Besides crossing points that has the most intersection of meridian qi in the back and abdomen, acupoints below the elbow and knee joints, such as five-shu points, source point, luo-connecting point, eight confluence point and lower he-sea point were also taken into account. As for compatibility of special acupoints, the supportive degree between back-shu acupoint and confluence points or front-mu acupoint was the highest; the selections of meridians mainly were Bladder Meridian, Conception Vessel and Spleen Meridian; and application of moxibustion was highly valued. In conclusion, it is feasible to apply data mining technology to the clinical literature research of ancient acupuncture and moxibustion, which can provide evidence for summary of the traditional classical theory.

[Family practice in a rural environment in the west of France (1908-1920): chronicle of mortality]

This paper reports about a manuscript from Doctor Pelletier who accounted the causes of death rate in a village of the Vendée: pneumopathy, typhoid, diarrhoea linked to unhealthiness provoked by stagnant waters.

The medical history of Thomas Jefferson (1743-1826)

Thomas Jefferson, the third President of the USA, was often the victim of a panoply of disorders including episodic headaches, dysentery, rheumatism, multiple bone fractures, malaria, possibly tuberculosis, dental problems, diabetes and urinary tract obstruction. Intermittently he experienced anxiety, depression and insomnia; he was an anxious, striving perfectionist, a compulsively controlled man.

[Miranda de Ebro: Medical condition of the concentration camp in the autumn of 1943]

Georges Morin's thesis (Algiers January 4 1944) allows to understand the sanitary conditions of the refugee camp at Miranda De Ebro (Spain) in the fall 1943. To avoid the Nazi occupation and the Obligatory Work Service in Germany 18,000 French got in Spain in 1943 and 10,000 including 39 physicians came through Miranda. The French were the majority and they created a Health Service separate from the official Spanish Health Service. The general dirtiness, the lack of water, the rudimentary conditions of lodging, the inadequacy and imbalance of food provoked two diseases among the young men: scabies and the so-called "mirandite" that is to say all the diarrheic diseases in the camp. Despite hard conditions of living the death rate in the camp remained smaller than crossing the Pyrenees from France where the danger threatened the escaped men.

From a pump handle to oral rehydration therapy: a model of translational research

Few afflictions have attracted as much attention and impacted on as many societal and biomedical areas as cholera. Dr. John Snow's studies launched the field of epidemiology, were early applications of medical cartography, and promoted the use of statistical methods in medicine. The finding that cholera was due to the ingestion of contaminated water lent to the demise of the prevalent "miasmatic theory of contagion," set the platform for the "germ theory of disease," and promoted the growth of public health concerns for water purification and sanitation. More recent attention to this disease led to the notion of "secretory diarrhea" and the translation of basic principles to the development of oral rehydration therapy and its "spin-offs" (Gatorade and Pedilyte).

Therapy for and Prevention of Traveler's Diarrhea

Acute diarrhea associated with international travel is commonly caused by enterotoxigenic Escherichia coli, enteroaggregative E. coli, or noroviruses. Early studies to define these enteropathogens took place at the University of Maryland during the Theodore E. Woodward years. Although a reduction in the rate of diarrhea may be possible through avoidance of foods and beverages likely to be contaminated, a more effective preventive strategy is to administer nonabsorbed (<0.4%) rifaximin each day during trips to areas where the risk of traveler's diarrhea is high (i.e., high-risk areas). For the self-treatment of diarrhea that occurs during travel, all persons planning trips to high-risk areas should take with them medication with expected activity against the prevalent bacterial enteropathogens: rifaximin (for the treatment of common afebrile, nondysenteric diarrhea), a fluoroquinolone, or azithromycin. Further study is needed to determine whether it is possible to avoid important morbidity associated with diarrhea and the development of postinfectious irritable bowel syndrome with chemoprophylaxis and/or early effective treatment.

Review article: the history of acute infectious diarrhoea management--from poorly focused empiricism to fluid therapy and modern pharmacotherapy

BACKGROUND

Acute diarrhoea management has progressed from largely ineffective measures in the early years to a more effective physiologic approach in recent years.

AIM

To review the history of acute diarrhoea management.

METHODS

Citations in PubMed were reviewed on 'acute diarrhoea treatment' along with an extensive file maintained by the corresponding author.

RESULTS

Freedom from diarrhoea was equated in early military conflicts with bravery and strength where diarrhoea-free soldiers had the 'guts' to fight. Until early 20th century, colonic irrigants, purgatives and emetic drugs were used to help eliminate undesired intestinal contents. Only a few early authorities suggested the need for replacement of fluids and salt, now standard treatment. Drugs aimed at diarrhoea symptom control have been broadly used for more than 100 years. The evolving history of one of those drugs, kaopectate is unappreciated. Once understanding the pathophysiology and infectious aetiology of acute diarrhoea, new oral fluids, pharmacologic agents designed to block specific secretory alterations and anti-infective drugs have been identified.

CONCLUSIONS

Physiologic and antimicrobial approaches to controlling diarrhoea can lead to reduction of stool number and enteric complaints, important in industrialized areas, with the potential for decreasing threat of fatal illness among infants in developing regions.

Diarrheal diseases in the history of public health

While the public health threat of HIV/AIDS in developing countries has drawn increasing attention from the international community for more than two decades, other health problems such as diarrheal diseases continue to contribute to higher morbidity and mortality rates in much of the developing world. This literature review is an account of both the history and current risks associated with diarrheal diseases.

Enterotoxigenic Escherichia coli in developing countries: epidemiology, microbiology, clinical features, treatment, and prevention

ETEC is an underrecognized but extremely important cause of diarrhea in the developing world where there is inadequate clean water and poor sanitation. It is the most frequent bacterial cause of diarrhea in children and adults living in these areas and also the most common cause of traveler's diarrhea. ETEC diarrhea is most frequently seen in children, suggesting that a protective immune response occurs with age. The pathogenesis of ETEC-induced diarrhea is similar to that of cholera and includes the production of enterotoxins and colonization factors. The clinical symptoms of ETEC infection can range from mild diarrhea to a severe cholera-like syndrome. The effective treatment of ETEC diarrhea by rehydration is similar to treatment for cholera, but antibiotics are not used routinely for treatment except in traveler's diarrhea. The frequency and characterization of ETEC on a worldwide scale are inadequate because of the difficulty in recognizing the organisms; no simple diagnostic tests are presently available. Protection strategies, as for other enteric infections, include improvements in hygiene and development of effective vaccines. Increases in antimicrobial resistance will dictate the drugs used for the treatment of traveler's diarrhea. Efforts need to be made to improve our understanding of the worldwide importance of ETEC.

Equitable child health interventions: the impact of improved water and sanitation on inequalities in child mortality in Stockholm, 1878 to 1925

Today, many of the 10 million childhood deaths each year are caused by diseases of poverty--diarrhea and pneumonia, for example, which were previously major causes of childhood death in many European countries. Specific analyses of the historical decline of child mortality may shed light on the potential equity impact of interventions to reduce child mortality. In our study of the impact of improved water and sanitation in Stockholm from 1878 to 1925, we examined the decline in overall and diarrhea mortality among children, both in general and by socioeconomic group. We report a decline in overall mortality and of diarrhea mortality and a leveling out of socioeconomic differences in child mortality due to diarrheal diseases, but not of overall mortality. The contribution of general and targeted policies is discussed.

History of U.S. Military Contributions to the Study of Diarrheal Diseases

Diarrhea, a scourge upon humanity since preliterate times, has been the particular nemesis of military forces. The Armed Forces of the United States have been in the forefront in the diagnosis, treatment, and prevention of diarrheal illness. U.S. military scientists and physicians implemented the first mandatory typhoid inoculation program, contributed to advances in water chlorination, and pioneered the use of antibiotics for typhoid fever. U.S. Navy physicians refined the intravenous treatment of cholera, reducing the death rate from 20% to less than 1%. Their studies of electrolyte and fluid balance in cholera, and the subsequent development of oral rehydration therapy for cholera and other diarrheal illness, have saved millions of lives worldwide. U.S. Army researchers refuted the desquamation theory of cholera pathogenesis, isolated the cholera exotoxin, and developed improved cholera vaccines. U.S. Army and Navy researchers pioneered the use of antibiotics for the treatment of typhoid fever, made major contributions to the treatment of dysentery, developed algorithms for the treatment of traveler's diarrhea, and continue active development of traveler's diarrhea and dysentery vaccines. U.S. military diarrheal research has directly contributed to the welfare of hundreds of millions of people.

History of the development of oral rehydration fluids

The development of oral rehydration fluid for the treatment of cholera and other diarrhoeal diseases has been regarded as one of the most important medical advances of the last century. This article summarises information on how this achievement was made possible. The development is traced from the historical empiric use of oral fluids for treating diarrhoea, to physiologic studies in animals that defined how glucose and sodium were coupled in absorption by the small intestine and finally, to the use of this knowledge in developing the simple effective solutions that were adopted by WHO as the mainstay of diarrhoeal therapy worldwide.

The sorbonnic trots: staging the intestinal distress of the roman catholic church in French Reform Theater

This essay surveys the use of the metaphors of illness, specifically those of constipation and diarrhea, in vernacular French Evangelical and Calvinist polemical theater of the 1520s and 30s (Berquin, Malingre, Marguerite d' Angoulême) through the 1560s (Badius). It considers the relatively frequent reference to staging of diagnosis, treatment, and cure in the context of contemporary medical belief and practice, and observes a shift in emphasis from optimistic prognosis and successful therapy of the earlier Evangelical period to negative pronouncement of imminent (and deserved) death in the later calvinist or Huguenot period at the start of the Wars of Religion.

Enteropathogenic Escherichia coli infection: history and clinical aspects

Diarrhoeagenic Escherichia coli remains an important cause of diarrhoeal disease worldwide. In terms of global public health, enteropathogenic E. coli (EPEC) and enterotoxigenic E. coli are the most important. However, enterohaemorrhagic E. coli has emerged as a cause of disease in developed countries in recent years, and a number of large outbreaks have been reported. Therefore, the importance of research into diarrhoeagenic E. coli remains an important issue. EPEC is the most widespread of the diarrhoeagenic E. coli and provides a good virulence model for other E. coli infections, as well as other pathogenic bacteria. Although the virulence mechanisms of E. coli are now better understood, there remains much to be learned before effective treatments can be developed. Type III secretion mechanisms, the locus of enterocyte effacement and various toxins are all involved in the pathogenesis of the various diarrhoeagenic E. coli and may provide targets for future therapies. This review aims to provide an update on the worldwide problem of diarrhoeagenic E. coli by focusing on EPEC, and describes the history of the organism, its incidence and the clinical aspects of infection.

The 18th C.L. Oakley Lecture. Pathogenicity of enteropathogenic Escherichia coli

Enteropathogenic Escherichia coli (EPEC) remain an important world-wide cause of diarrhoeal disease and mortality of infants and young children. Research programmes around the world have, in recent times, made enormous strides towards a better understanding of EPEC pathogenesis, yielding unique insights into the molecular intercourse between host and pathogen. Recombinant DNA and cell biology techniques have provided powerful tools, giving the first intriguing glimpses of a wealth of bacterial products mediating complex host:pathogen interactions involving the subversion of normal host signalling processes. Much has been discovered since 1945, when E. coli was first implicated as a cause of diarrhoea. However, many questions remain unanswered and many more remain unasked. Much remains to be discovered, especially in the area of molecular interactions between host and pathogen and how they relate to the manifestation of disease in the patient.

Overview of viral gastroenteritis

Diarrheal illnesses in humans have been recognized since antiquity. Such illnesses continue to take a great toll of lives, with a disproportionately high mortality in infants and young children in developing countries. Bacteriologic and parasitologic advances made during the past century led to the discovery of the etiology of some of the diarrheal illnesses, but the etiology of the major portion remained unknown. It was assumed that viruses caused most of these illnesses because: (i) bacteria were recovered from only a small proportion of episodes, and (ii) bacteria-free filtrates were found to induce gastroenteritis in adult volunteer studies. However, an etiologic agent could not be recovered despite the "golden age" of virology in the 1950's and 1960's when tissue culture technology enabled the discovery of numerous cultivatable enteric viruses, none of which emerged as an important etiologic agent of gastroenteritis. The discoveries of the Norwalk virus in 1972, and of rotaviruses in 1973, both without the benefit of in vitro tissue culture systems, ushered in a new era in the study of the etiology of viral gastroenteritis. The Norwalk virus was found to be an important cause of non-bacterial epidemic gastroenteritis in adults and older children, and rotaviruses were shown to be the single most important etiologic agents of severe diarrheal illnesses of infants and young children in both developed and developing countries. With the major advances in the study of rotaviruses, there is a high degree of optimism that in the not-too-distant future, a rotavirus vaccine will be available. In addition, the recent molecular biologic advances in the study of the Norwalk and Norwalk-like viruses, now firmly established as caliviviruses, represent a major new horizon in the study of these viruses.

Magic bullet: the history of oral rehydration therapy

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[Development of a rehydration therapy in diarrheic disease. 1980]

Intravenous rehydration is required only in patients with severe diarrhea due to V. cholerae who are in shock, with absent peripheral pulse and blood pressure; when the shock has been corrected, rehydration can be completed using an oral rehydration solution. The intravenous solution to be used is 5:4: 1 (5g of sodium chloride, 4g of sodium bicarbonate and 1g of potassium chloride per liter) or a comparable commercial alkaline solution. For oral rehydration a solution is used containing 3.5 g sodium chloride, 2.5g sodium bicarbonate, 1.5g potassium chloride and 20g of glucose (or 40g of sucrose) per liter. These fluids are administered in a volume replacing the amount lost before treatment was initiated and the fluids lost in the continuing diarrhea. With this management, a case fatality rate of 50% in the untreated falls to less than 1%. The addition of antibiotics such as tetracycline and furazolidone reduces the duration of diarrhea and the need for continuing fluid balance observation. Intravenous rehydration of severe diarrhea cases with normal saline solution or with 5% glucose solution increases the acidosis with resulting veno-constriction, which favors the pooling of blood in the heart and the pulmonary circulation leading to cardiac overload and then failure and circulatory peripheral collapse. When acidosis is corrected by the sodium bicarbonate solution and with adequate fluid replacement, normal hemodynamics are reestablished and the patient immediately recovers from the collapse. In cases of mild or moderate diarrhea, replacement entirely by oral rehydration of the estimated volume of lost fluid alone is usually sufficient. This management of diarrhea is applicable for diarrhea from any cause, including enterotoxigenic Escherichia coli, Rotavirus, Salmonella and Shigella as well as Vibrio cholerae.

Health and disease on the western frontier. A bicentennial appreciation

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[Old and new data on diarrhetic diseases in childhood I. Etiology and pathophysiology]

Etiology and Pathophysiology. The present article is a comprehensive review of recent research results in the field of acute diarrhea. The most important new idea in contrast to older views is that almost all acute diarrheas are associated with a disturbance of intestinal bacterial homeostasis: overgrowth of the small intestine with apathogenic or pathogenic organisms is followed by changes in intestinal metabolism with increase in intestinal water and electrolyte secretion. Anaerobic organisms cause by enzymatic deconugation and dydroxylation of bile acids secretion of fluid into the small intestine and inhibition of fluid absorption from the large intestine. 10-OH-fatty acids, which are formed intraluminally by enzymatic hydroxylation of long-chain unsaturated fatty acids from the diet by similar anaerobic organisms, produce profuse secretion of fluid into the small intestine. The ability of numerous strains of E. coli to produce enterotoxin, which has a qualitatively similar action to cholera toxin, is now considered to be a major cause of infantile diarrhea. The separation of two completely different pathophysiologic mechanisms of E. Coli, the enterotoxic and the enteroinvasive action which are determined by extranuclear chromosomal material, is an important result of recent research. Overgrowth of the small intestine with different bacteria is followed by loss of actiivity of lactase, and later of all disaccharidases in the intestinal mucosa.